Contract Pharmacy Details

WALGREEN EASTERN CO., INC.
DSH330194 MAIMONIDES MEDICAL CENTER

Covered Entity Details

Entity Name

MAIMONIDES MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330194

Entity Address

4802 TENTH AVE.
BROOKLYN, NY 11219

Medicare Provider Number

330194

Participating Start Date

10/1/2004

Last Recertification Date

8/30/2024

Pharmacy Details

Pharmacy Name

WALGREEN EASTERN CO., INC.

Pharmacy Address

DBA: WALGREENS #15097
589 PROSPECT AVE
BROOKLYN, NY 11215

Pharmacy Comments

Contract Details

Approval Date

10/13/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/24/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

KENNETH D. GIBBS, CEO
(718) 283-6575

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/13/2016

340B Drug Pricing Program Database